1144282757 NPI number — GINA M BASELLO DO

Table of content: GINA M BASELLO DO (NPI 1144282757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144282757 NPI number — GINA M BASELLO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASELLO
Provider First Name:
GINA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144282757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 MARCUS DR
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-4230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-391-7887
Provider Business Mailing Address Fax Number:
631-454-4163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133-03 JAMAICA AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND HILL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-657-7093
Provider Business Practice Location Address Fax Number:
718-558-5314
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  222962 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02312554 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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